The objective of this study was to explore cancer patients' perspectives regarding cancer, as well as to understand their experiences relevant to modern cancer therapies. The current study portrays the participants from a local hospital in Malaysia, and represents a diverse group in terms of their age, ethnic background, cancer type and stage. As reported previously [22
], risk perceptions of cancer are deeply influenced by specific cultural beliefs, we hypothesised that there will be differences in beliefs regarding the causes of cancer among patients from different ethnic backgrounds; this appeared not to be so, as patients related it more to their lifestyle habits and family history rather than any specific cultural beliefs. Genetic risk factors and their potential influence on the process of risk perception have been widely evaluated through qualitative investigations [24
]. In a review of qualitative studies regarding ways in which lay people construct and experience cancer risk, it is concluded that risk perception is strongly influenced by one's own experience of having or caring for cancer patients [25
]. Despite having a strong family history of cancer, the risk perceptions among the study participants were found to be very low, and a sense of perceived susceptibility to cancer was completely absent. The concept of perceived susceptibility has been found to be predictive of engaging in protective health behaviours [26
]. During the discussion, most of the participants did not admit to having cancer screening prior to their diagnosis. In general, the likelihood of engaging in screening activities for cancer depends only on how much patients found themselves vulnerable of getting cancer. Our study provides basic information to clinicians regarding the importance of incorporating health beliefs prior to designing any educational or interventional programs.
The life style habits such as smoking, is no longer in debate as a potential cause of cancer. In the US, smoking accounts for at least 30% of all cancer deaths and 87% of lung cancer deaths [27
]. It is distressing to note that despite numerous efforts aimed at discouraging smoking among Malaysians, every day approximately 50 teenagers under the age of 18 begin smoking [28
]. A focus group investigation among smokers in Malaysia concluded that misconceptions and false beliefs such as 'smoking after food' or 'drinking water after smoking to moisturise the throat or lungs' to prevent harmful effects of smoking clearly indicate a poor level of knowledge about smoking and its harmful effects on health [29
]. A sign of clear disappointment and self-guilt observed during our interviews where patients admitted their smoking habits as a reason for their cancer. An in-depth investigation about lay beliefs should be conducted and must be incorporated prior to designing any health campaigns. Study participants with good dietary and lifestyle habits rejected the idea of lifestyle habits as a cause of cancer. Patients related it more to luck or God's will. Despite being from three different religions, i.e., Islam, Hinduism and Buddhism, patients repeatedly used the word God, and God's will when referencing being diagnosed or possibly being cured of cancer. Many acknowledged that the diagnosis of cancer is a wakeup call to absolve oneself from sin or other spiritual contamination. Consistent with our findings, spirituality has been found to be one of the widespread strategies among cancer patients coping with cancer [30
]. The participants of the study described numerous methods of coping, such as reciting verses from the Holy Book 'Al Quran'
among Muslims, regular visits to the temples among Hindus and numerous types of faith healing physical exercises among Buddhist cancer patients.
The study results suggest that the perception of a treatment plays an important role in treatment decision-making. Patients demonstrated an acceptable awareness and knowledge regarding modern therapies. The most dominant reason why patients perceived the conventional modern therapies as effective was the scientific method of preparation. At the same time, the perceived poor effectiveness of traditional therapies in curing cancer describes the importance of patients' knowledge about effective ways to treat cancer. During the last few decades, most of the studies focused on the reasons why patients used traditional medicines; however, patients in this study provide the evidence as to why they decided to seek modern therapies [33
]. During the discussion, numerous themes did emerge about the perceived effectiveness of traditional medicines for cancer cure, but as this is not the part of the objectives of this study, this will not be discussed. It is imperative to note that Malaysians are reported to spend approximately $500 (US) million on traditional medicines, compared with only $300 (US) million for western medicines; however, little is known about how they perceived the effectiveness of these modalities, their potential risks and the duration of use [35
]. Further analyses of the interviews of the participants could throw some light onto these perceptions. The Malaysian government has taken a proactive step in implementing the integrative medicines in some of the government hospitals. The desire of the government is to encourage the rational use of traditional medicines by registered traditional practitioners for chronic disease patients including cancer; however, patients' and physicians' perceptions regarding such integration are still questionable [36
Cost of treatment is reported as a barrier in seeking treatment among cancer patients [37
]. However, our results showed that the participants perceived modern cancer treatments as effective due to the high cost; additionally, the high cost was a reason for compliance to their treatment. The Malaysian health care system offers free treatment to all Malaysians for most of the chronic diseases; nevertheless the high cost of modern therapies sometimes forces the public to fork over their life savings.
The adverse effects of conventional treatments and its psychological effects on patients' quality of life have been widely studied among cancer patients [38
]. In some cases, perceived severity of side effects due to conventional therapies is one of the reasons for partially or completely defaulting proven therapies [41
]. Our findings were consistent with others, where fears of undesirable effects of surgery on the body and side effects due to chemotherapies were a few of the initial reasons in delays in seeking cancer treatment. At the same time, effective management of the side effects was also found to support patients' preference to continue with modern therapies. It should be appreciated that innovative methods such as effective anti-emetic regimen with newer agents and fully implantable venous devices are some of the initiatives taken by the government to improve cancer patients' compliance towards modern cancer therapies [13
The study participants were receiving treatment in the hospitals at the time of interview, which may explain some of their positive attitudes towards conventional therapies. Conducting similar studies among patients who defaulted their therapies partially or completely may give better insights into the perceived effectiveness of conventional therapies to cure cancer. The paucity of the funding restricted the study to only one hospital in Malaysia; however, significant efforts were made to include as wide a range of patients from diverse ethnic backgrounds and a variety of different types of cancer which may help to generalize the data to some extent.